ICD-9-CM and MS-DRG Update FY 2012

ICD-9-CM and MS-DRG Update FY 2012
Presented by: Laurie M. Johnson, MS, RHIA, CPC-H
AHIMA Certified ICD-10-CM/PCS Trainer
September 9, 2011

Session Objectives
• Review new ICD-9-CM Codes

• Review latest changes to ICD-10

• Understand the most recent changes to MS-DRGs

• Discuss other topics in FY12 Final Rule

Proprietary and Confidential. Do not distribute. 2

1

ICD-9-CM Updates FY 2012

Presented by: Laurie M. Johnson, MS, RHIA, CPC-H
OptumInsight
September 9, 2011

Overall New Code Distribution
• New Diagnosis Codes • New Diagnosis Codes (con’t)
– Chapter 1 (001 – 139) - 4 – Chapter 12 (680 – 709) - 2
– Chapter 2 (140 – 239) - 40 – Chapter 13 (710 – 739) - 1
– Chapter 3 (240 – 279) - 0 – Chapter 14 (740 – 759) - 3
– Chapter 4 (280 – 289) - 12 – Chapter 15 (760 – 779) - 0
– Chapter 5 (290 – 319) - 4 – Chapter 16 (780 – 799) - 4
– Chapter 6 (320 – 389) - 13 – Chapter 17 (800 – 999) - 19
– Chapter 7 (390 – 459) - 6 – Chapter 18 (V01 – V91) - 17
– Chapter 8 (460 – 519) - 28 – Chapter 19 (E codes) -
– Chapter 9 (520 – 579) - 5 • New Procedure Codes - 19
– Chapter 10 (580 – 629) - 6
– Chapter 11 (630 – 679)- 4


2

FY12 Update vs. Documentation
• Malignant neoplasm of skin vs. basal cell carcinoma vs. squamous cell
carcinoma
• Specific types of thalassemia
• Antineoplastic chemotherapy causing pancytopenia vs. other drug
induced pancytopenia
• Acquired vs. congenital hemophilia
• Behavior disorder associated with dementia
• Specific type of glaucoma
• Stages of glaucoma (mild, moderate, severe, indeterminate)
• Saddle embolism vs. other embolism of abdominal aorta
• Primary vs. Secondary vs. Chronic pneumothorax
• Acute vs. Chronic vs. Acute/Chronic respiratory failure associated with
trauma and surgery
• Relationship of condition to a procedure


New Diagnosis Codes - Infections
Diagnosis Description
Code
041.41 Shiga toxin-producing Escherichia coli [E. coli] (STEC) O157

041.42 Other specified Shiga toxin-producing Escherichia coli [E. coli]
(STEC)
041.43 Shiga toxin-producing Escherichia coli [E. coli] (STEC),
unspecified
041.49 Other and unspecified Escherichia coli [E. coli]


3

New Diagnosis Codes - Neoplasms
Diagnosis Code Description CC
Code
173.00 Unspecified malignant neoplasm of skin of lip N
173.01 Basal cell carcinoma of skin of lip N
173.02 Squamous cell carcinoma of skin of lip N
173.09 Other specified malignant neoplasm of skin of lip N
173.10 Unspecified malignant neoplasm of eyelid, including N
canthus
173.11 Basal cell carcinoma of eyelid, including canthus N
173.12 Squamous cell carcinoma of eyelid, including canthus N
173.19 Other specified malignant neoplasm of eyelid, including N
canthus


Code
173.20 Unspecified malignant neoplasm of skin of ear and external N
auditory canal
173.21 Basal cell carcinoma of skin of ear and external auditory canal N
173.22 Squamous cell carcinoma of skin of ear and external auditory N
canal
173.29 Other specified malignant neoplasm of skin of ear and external N
auditory canal
173.30 Unspecified malignant neoplasm of skin of other and N
unspecified parts of face
173.31 Basal cell carcinoma of skin of other and unspecified parts of N
face
173.32 Squamous cell carcinoma of skin of other and unspecified parts N
of face
173.39 Other specified malignant neoplasm of skin of other and N
unspecified parts of face

4

Code
173.40 Unspecified malignant neoplasm of scalp and skin of N
neck
173.41 Basal cell carcinoma of scalp and skin of neck N
173.42 Squamous cell carcinoma of scalp and skin of neck N
173.49 Other specified malignant neoplasm of scalp and skin of N
neck
173.50 Unspecified malignant neoplasm of skin of trunk, except N
scrotum
173.51 Basal cell carcinoma of skin of trunk, except scrotum N
173.52 Squamous cell carcinoma of skin of trunk, except scrotum N
173.59 Other specified malignant neoplasm of skin of trunk, except N
scrotum


Code
173.60 Unspecified malignant neoplasm of skin of upper limb, N
including shoulder
173.61 Basal cell carcinoma of skin of upper limb, including N
shoulder
173.62 Squamous cell carcinoma of skin of upper limb, including N
shoulder
173.69 Other specified malignant neoplasm of skin of upper limb, N
including shoulder
173.70 Unspecified malignant neoplasm of skin of lower limb, N
including hip
173.71 Basal cell carcinoma of skin of lower limb, including hip N
173.72 Squamous cell carcinoma of skin of lower limb, including hipN
173.79 Other specified malignant neoplasm of skin of lower limb, N
including hip


5

Code
173.80 Unspecified malignant neoplasm of other specified sites of N
skin
173.81 Basal cell carcinoma of other specified sites of skin N
173.82 Squamous cell carcinoma of other specified sites of skin N
173.89 Other specified malignant neoplasm of other specified sites N
of skin
173.90 Unspecified malignant neoplasm of skin, site unspecified N
173.91 Basal cell carcinoma of skin, site unspecified N
173.92 Squamous cell carcinoma of skin, site unspecified N
173.99 Other specified malignant neoplasm of skin, site unspecified N


Skin Cancers
• Basal Cell Carcinoma
– Basal cell carcinoma is a type of nonmelanoma skin cancer, and is
the most common form of cancer in the United States.
– According to the American Cancer Society, 75% of all skin cancers
are basal cell carcinomas.
– Begins in the epidermis
– At risk if you are blond haired, blue/green eyed, light skinned
• Squamous Cell Carcinoma
– Squamous cell cancer occurs when cells in the skin start to change.
– The changes may begin in normal skin or in skin that has been
injured or inflamed.
– Most skin cancers occur on skin that is regularly exposed to sunlight
or other ultraviolet radiation.
– Skin cancer is most often seen in people over age 50.
– At risk if you are blond haired, blue/green eyed, light skinned


6

New Diagnosis Codes – Blood/Blood Forming Organs
Diagnosis Code Description CC/
Code MCC
282.40* Thalassemia, Unspecified N

282.43* Alpha thalassemia N
282.44* Beta thalassemia N
282.45* Delta-beta thalassemia N
282.46* Thalassemia minor N
282.47* Hemoglobin E-beta thalassemia N
284.11* Antineoplastic chemotherapy induced pancytopenia MCC


Thalassemia
• Thalassemia is a blood disorder passed down through families (inherited) in
which the body makes an abnormal form of hemoglobin, the protein in red
blood cells that carries oxygen.
• The disorder results in excessive destruction of red blood cells, which leads to
anemia.
• There are two main types of thalassemia:
– Alpha thalassemia occurs when a gene or genes related to the alpha globin
protein are missing or changed (mutated).
– Beta thalassemia occurs when similar gene defects affect production of the
beta globin protein.
• Symptoms can include:
– Bone deformities in the face
– Fatigue
– Growth failure
– Shortness of breath
– Yellow skin (jaundice)


7

New Diagnosis Codes – Blood/Blood Forming Organs
Code MCC

284.12* Other drug-induced pancytopenia MCC
284.19* Other pancytopenia CC
286.52 Acquired hemophilia CC
286.53 Antiphospholipid antibody with hemorrhagic disorder CC
286.59 Other hemorrhagic disorder due to intrinsic circulating CC
anticoagulants, antibodies, or inhibitors


New Diagnosis Codes - Mental
Code MCC
294.20 Dementia, unspecified, without behavioral disturbance N
294.21 Dementia, unspecified, with behavioral disturbance CC2

310.81 Pseudobulbar affect N

310.89 Other specified nonpsychotic mental disorders following N
organic brain damage


8

New Diagnosis Codes - Nervous
Code MCC

331.6 Corticobasal degeneration N
348.82 Brain death MCC2
358.30 Lambert-Eaton syndrome, unspecified CC
358.31 Lambert-Eaton syndrome in neoplastic disease CC
358.39 Lambert-Eaton syndrome in other diseases classified CC
elsewhere


Lambert-Eaton Syndrome
• Lambert-Eaton syndrome is a disorder in which faulty communication between
nerves and muscles leads to muscle weakness
• Lambert-Eaton syndrome occurs when nerves cells do not release enough of a
chemical called acetylcholine. This chemical transmits impulses between
nerves and muscles.
• Symptoms may include:
– Weakness or loss of movement that can be more or less severe, including:
• Difficulty chewing
• Difficulty climbing stairs
• Difficulty lifting objects
• Difficulty talking
• Drooping head
• Need to use hands to get up from sitting or lying positions
– Swallowing difficulty, gagging, or choking
• Vision changes such as:
• Blurry vision
• Double vision
• Problems keeping a steady gaze


9

New Diagnosis Codes - Nervous
Code MCC
365.05 Open angle with borderline findings, high risk N
365.06 Primary angle closure without glaucoma damage N
365.70 Glaucoma stage, unspecified N
365.71 Mild stage glaucoma N
365.72 Moderate stage glaucoma N
365.73 Severe stage glaucoma N
365.74 Indeterminate stage glaucoma N
379.27* Vitreomacular adhesion N


New Diagnosis Code - Circulatory
Code MCC
414.4* Coronary atherosclerosis due to calcified coronary N
lesion
415.13 Saddle embolus of pulmonary artery MCC

425.11* Hypertrophic obstructive cardiomyopathy CC
425.18* Other hypertrophic cardiomyopathy CC

444.01 Saddle embolus of abdominal aorta MCC
444.09 Other arterial embolism and thrombosis of abdominal CC
aorta


10

New Diagnosis Codes - Respiratory
Code MCC
488.81* Influenza due to identified novel influenza A virus with MCC
pneumonia
488.82* Influenza due to identified novel influenza A virus with N
other respiratory manifestations
488.89* Influenza due to identified novel influenza A virus with N
other manifestations
508.2* Respiratory conditions due to smoke inhalation N
512.2* Postoperative air leak CC
512.81* Primary spontaneous pneumothorax CC
512.82* Secondary spontaneous pneumothorax CC
512.83* Chronic pneumothorax CC
512.84* Other air leak CC
512.89* Other pneumothorax CC


Code MCC
516.30 Idiopathic interstitial pneumonia, not otherwise specified N2
516.31 Idiopathic pulmonary fibrosis N
516.32 Idiopathic non-specific interstitial pneumonitis N
516.33* Acute interstitial pneumonitis CC
516.34 Respiratory bronchiolitis interstitial lung disease N
516.35 Idiopathic lymphoid interstitial pneumonia CC
516.36 Cryptogenic organizing pneumonia CC
516.37 Desquamative interstitial pneumonia CC
516.4 Lymphangioleiomyomatosis MCC
516.5 Adult pulmonary Langerhans cell histiocytosis CC


11

Code MCC
516.61 Neuroendocrine cell hyperplasia of infancy MCC
516.62 Pulmonary interstitial glycogenosis MCC
516.63 Surfactant mutations of the lung MCC
516.64 Alveolar capillary dysplasia with vein misalignment MCC
516.69 Other interstitial lung diseases of childhood MCC
518.51* Acute respiratory failure following trauma and surgery MCC
518.52* Other pulmonary insufficiency, not elsewhere classified, MCC
following trauma and surgery
518.53* Acute and chronic respiratory failure following trauma and MCC
surgery


New Diagnosis Codes - Digestive

Code MCC
539.01 Infection due to gastric band procedure CC
539.09 Other complications of gastric band procedure CC

539.81 Infection due to other bariatric procedure CC
539.89 Other complications of other bariatric procedure CC
573.5* Hepatopulmonary syndrome N


12

New Diagnosis Code - Urinary
Code MCC
596.81 Infection of cystostomy CC
596.82 Mechanical complication of cystostomy CC
596.83 Other complication of cystostomy CC
596.89 Other specified disorders of bladder N
629.31 Erosion of implanted vaginal mesh and other prosthetic N
materials to surrounding organ or tissue
629.32 Exposure of implanted vaginal mesh and other prosthetic N
materials into vagina


New Diagnosis Codes - Pregnancy
Code MCC
631.0 Inappropriate change in quantitative human chorionic N
gonadotropin (hCG) in early pregnancy
631.8 Other abnormal products of conception N
649.81 Onset (spontaneous) of labor after 37 completed weeks N
of gestation but before 39 completed weeks gestation,
with delivery by (planned) cesarean section,
delivered, with or without mention of antepartum
condition
649.82 Onset (spontaneous) of labor after 37 completed weeks N
of gestation but before 39 completed weeks gestation,
with delivery by (planned) cesarean section,
delivered, with mention of postpartum complication


13

New Diagnosis Codes – Skin/Subcutaneous
Code MCC
704.41 Pilar cyst N

704.42 Trichilemmal cyst N


Pilar Cyst
• Pilar cysts are common, occurring in 5-10% of the population.[1]
Greater than 90% occur on the scalp, where pilar cysts are the most
common cutaneous cyst.
• Pilar cysts are the second most frequent type of cyst on the head and
neck.[2, 3] Pilar cysts are almost always benign, malignant
transformation being extremely rare.
• Pilar cysts may be sporadic or may be autosomal dominantly
inherited.[4] They contain keratin and its breakdown products and are
lined by walls resembling the external (outer) root sheath of the hair.


14

Trichilemmal Cyst
• Trichilemmal cysts are derived from the outer root sheath of the hair
follicle.
• Their origin is unknown, but it has been suggested that they are
produced by budding from the external root sheath as a genetically
determined structural aberration.
• They arise preferentially in areas of high hair follicle concentrations,
therefore, 90% of cases occur on the scalp.
• They are solitary in 30% of cases and multiple in 70% of cases


New Diagnosis Codes - Musculoskeletal

Code MCC
726.13* Partial tear of rotator cuff N


15

New Diagnosis Codes – Congenital Anomalies
Code MCC
747.31 Pulmonary artery coarctation and atresia MCC

747.32 Pulmonary arteriovenous malformation MCC

747.39 Other anomalies of pulmonary artery and pulmonary MCC
circulation


New Diagnosis Codes – Perinatal Conditions


16

New Diagnosis Codes – Signs/Symptoms
Code MCC
793.11* Solitary pulmonary nodule N

793.19* Other nonspecific abnormal finding of lung field N

795.51* Nonspecific reaction to tuberculin skin test without N
active tuberculosis
795.52* Nonspecific reaction to cell mediated immunity N
measurement of gamma interferon antigen response
without active tuberculosis


New Diagnosis Codes – Injury/Poisoning
Code MCC
808.44 Multiple closed pelvic fractures without disruption of CC
pelvic circle
808.54 Multiple open pelvic fractures without disruption of MCC
pelvic circle
996.88 Complications of transplanted organ, stem cell CC
997.32 Postprocedural aspiration pneumonia CC
997.41 Retained cholelithiasis following cholecystectomy CC
997.49 Other digestive system complications CC
998.00* Postoperative shock, unspecified CC


17

Code MCC
998.01* Postoperative shock, cardiogenic MCC
998.02* Postoperative shock, septic MCC
998.09* Postoperative shock, other MCC
999.32* Bloodstream infection due to central venous catheter CC
999.33* Local infection due to central venous catheter CC
999.34* Acute infection following transfusion, infusion, or CC
injection of blood and blood products



Code MCC
999.41 Anaphylactic reaction due to administration of blood and CC
blood products
999.42 Anaphylactic reaction due to vaccination CC
999.49 Anaphylactic reaction due to other serum CC
999.51 Other serum reaction due to administration of blood and CC
blood products
999.52 Other serum reaction due to vaccination CC
999.59 Other serum reaction CC


18

New Diagnosis Codes – V Codes
Code MCC
V12.21 Personal history of gestational diabetes N
V12.29 Personal history of other endocrine, metabolic, and N
immunity disorders
V12.55 Personal history of pulmonary embolism N
V13.81 Personal history of anaphylaxis N
V13.89 Personal history of other specified diseases N
V19.11 Family history of glaucoma N
V19.19 Family history of other specified eye disorder N
V23.42 Pregnancy with history of ectopic pregnancy N
V23.87 Pregnancy with inconclusive fetal viability N
V40.31* Wandering in diseases classified elsewhere N
V40.39* Other specified behavioral problem N


New Diagnosis Codes – V Codes
Code MCC
V54.82 Aftercare following explantation of joint prosthesis N
V58.68* Long term (current) use of bisphosphonates N
V87.02 Contact with and (suspected) exposure to uranium N
V88.21 Acquired absence of hip joint N
V88.22 Acquired absence of knee joint N
V88.29 Acquired absence of other joint N

•Notes:
•* These diagnosis codes were discussed at the March 9–10, 2011 ICD-9-CM Coordination
and Maintenance Committee meeting and were not finalized in time to include in the FY
2012 IPPS/LTCH PPS proposed rule. They will be implemented on October 1, 2011.
•1 Secondary diagnosis of major problem
•2 Please note the CC designation has changed from the proposed rule.
•3 On "Secondary Diagnosis" list
•4 Significant trauma body site - pelvis or spine


19

New Procedure Codes
Proc Code Description OR?
Code
02.21* Insertion or replacement of external ventricular drain [EVD] Y
02.22* Intracranial ventricular shunt or anastomosis Y
12.67* Insertion of aqueous drainage device Y
17.53* Percutaneous atherectomy of extracranial vessel(s) Y
17.54* Percutaneous atherectomy of intracranial vessel(s) Y
17.55* Transluminal coronary atherectomy Y
17.56* Atherectomy of other non-coronary vessel(s) Y
17.81* Insertion of antimicrobial envelope N


New Procedure Codes
Proc Code Description OR?
Code
35.05* Endovascular replacement of aortic valve Y
35.06* Transapical replacement of aortic valve Y
35.07* Endovascular replacement of pulmonary valve Y
35.08* Transapical replacement of pulmonary valve Y
35.09* Endovascular replacement of unspecified heart valve Y
38.26 Insertion of implantable pressure sensor without lead for Y
intracardiac or great vessel hemodynamic monitoring
39.77* Temporary (partial) therapeutic endovascular occlusion of vesselY
39.78* Endovascular implantation of branching or fenestrated graft(s) Y
in aorta
43.82* Laparoscopic vertical (sleeve) gastrectomy Y
68.24* Uterine artery embolization [UAE] with coils Y
68.25* Uterine artery embolization [UAE] without coils Y


20

ICD-9-CM Official Coding and Reporting
Guideline Changes

2012 ICD-9-CM Guideline Update
• Initially released on August 11, 2011
• Revised version released August 23, 2011
• 107 pages
• Available at
http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf
• Updates
– Documentation of Complications of Care
– Glaucoma
– POA
• Congenital


21

Documentation of Complications of Care
• New Section
• Documentation of Complications of care
– Code assignment is based on the provider’s documentation of the
relationship between the condition and the care or procedure. The
guideline extends to any complications of care, regardless of the
chapter the code is located in. It is important to note that not all
conditions that occur during or following medical care or surgery are
classified as complications. There must be a cause-and-effect
relationship between the care provided and the condition, and an
indication in the documentation that it is a complication. Query the
provider for clarification, if the complication is not clearly
documented.
• Use additional code to identify nature of complication
– An additional code identifying the complication should be assigned
with codes in categories 996-999, Complications of Surgical and
Medical Care NEC, when the additional code provides greater
specificity as to the nature of the condition. If the complication code
fully describes the condition, no additional code is necessary.


Documentation of Complications of Care
• Kidney transplant complications
– Conditions that affect the function of the transplanted kidney, other
than CKD, should be assigned code 996.81, Complications of
transplanted organ, Kidney, and a secondary code that identifies the
complication.


22

Categories of V Codes
• Contact/Exposure
– Codes V15.84 – V15.86 describe contact with or (suspected)
exposure to asbestos, potentially hazardous body fluids, and lead.
– Subcategories V87.0 – V87.3 describe contact with or (suspected)
exposure to hazardous metals, aromatic compounds, other
potentially hazardous chemicals, and other potentially hazardous
substances.


Glaucoma
• Glaucoma – for codes 365.1 – 365.6, add code from subcategory 365.7 to
identify the glaucoma stage
• Bilateral glaucoma with same stage
– Assign code for glaucoma type
– Assign code for glaucoma stage
• Bilateral glaucoma with different stages
– Assign code for glaucoma type
– Assign code for highest stage of glaucoma documented
• Bilateral glaucoma with different types and different stages
– Assign code for each type of glaucoma
– Assign code for highest stage of glaucoma documented
• Glaucoma stage evolves during admission
– Assign highest glaucoma stage documented
• Indeterminate stage of glaucoma
– 365.74 (glaucoma of indeterminate stage) is assigned based on clinical
documentation
– Glaucoma stage can not be clinically determined
– Do not confuse with glaucoma stage unspecified, 374.70


23

Present on Admission Updates
• Congenital conditions and anomalies
– Assign “Y” for congenital conditions and anomalies, except for
categories 740-759, Congenital anomalies, which are on the
exempt list. Congenital conditions are always considered present
on admission.


ICD-10 Update for FY 2012

24

ICD-10 in the US
• Final Rule was published January 16, 2009 with an effective date of
March 17, 2009 and an implementation date of October 1, 2013.
• ICD-10-CM is administered by NCVHS.
• ICD-10-PCS is administered by CMS.
• New updates to ICD-10 will be published in late December/early
January 2011.


ICD-10 Coding Guidelines
• 2011 Diagnosis version available (replaces 2010 version)
• 2012 Diagnosis version will not be posted until after December 1,2011
• Diagnosis Guidelines are available at:
http://www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf
• Contact for ICD-10-CM questions, contact Donna Pickett at dfp4@cdc.gov

• 2012 Procedure codes available at
http://www.cms.gov/ICD10/11b15_2012_ICD10PCS.asp#TopOfPage

2011 New Revised Deleted 2012
Total Codes Codes Codes Total
72,081 1,182 381 1,345 71,918

• Procedure Guidelines are available at:
http://www.cms.gov/ICD10/Downloads/PCS_2012_guidelines.pdf
• 2012 ICD-10-PCS GEMs will be posted October 1, 2011 with the reimbursement mapper posted after
December 1, 2011.
• Contact for ICD-10-PCS: Patricia.brooks2@cms.hhs.gov


25

September 2011 Coordination & Maintenance
Committee Meeting Report
• Coordination & Maintenance Meeting will meet on September 14th.
– Procedure codes will be discussed from 9:00 AM – 12:30 PM EDT
• The agenda is available at
http://www.cms.gov/ICD9ProviderDiagnosticCodes/Downloads/09
1411_Agenda.pdf
• Electromagnetic Tip for Nodules
• ICD-10-PCS
– Diagnosis codes will be discussed from 1:30 PM – 5:30 PM
• The agenda is available at
http://www.cdc.gov/nchs/data/icd9/tentativeagendaSept142011.p
df
• ICD-10-CM Diagnoses
– You can attend via audioconference without registering.
– Dial in access for external participants is 1-877-267-1577
Meeting ID: 1234


Inpatient Prospective Payment System FY12

26

Final Rule FY2012
• Available at http://www.gpo.gov/fdsys/pkg/FR-2011-08-18/pdf/2011-
19719.pdf.
• Final Rule was released In Federal Register on August 18, 2011
• 751 MS-DRGs across 25 MDCs
• Relative weight calibration was based on MedPAR data from October 1,
2009 through September 30, 2010 based on bills received by March 31,
2011.
• MS-DRGs are based on:
– Age
– Sex
– Principal Diagnosis
– DRG Operating Room Procedures
– CC/MCC
– Discharge Status
– Present on Admission (effective 10/1/2008)


Documentation and Coding Adjustment
• Implementation of the MS-DRGs included an adjustment to payments based
on expected documentation and coding improvement.
• For FY 2011 Rule setting MedPAR data 2009 was reviewed to estimate the
percentage of increased payments due to improvements in Documentation
and Coding. This was determined to be 5.4 % based on available data.
• The impact of documentation and coding from FY09 (FY08 and FY09)
yields a cumulative coding and documentation adjustment of 1.5%
• A 2.9% adjustment to the standardized rate will be implemented for FY11
(total adjustment of 4.4%).
• CMS is planning to implement an increase of 2.0% adjustment for FY12.


27

Current Hospital Acquired Conditions

Currently designated conditions which may affect reimbursement
if the only CC or MCC on the case include

HAC CC/MCC
(ICD-9-CM Code)

Foreign Object Retained After Surgery 998.4 (CC)
998.7 (CC)

Air Embolism 999.1 (MCC)
Blood Incompatibility 999.60, 999.61, 999.62,
999.63, 999.69 (CC)
Pressure Ulcer Stages III & IV 707.23 (MCC)
707.24 (MCC)


HAC CC/MCC /ICD-9-CM
Code
Falls and Trauma: Codes within these ranges
- Fracture on the CC/MCC list:
- Dislocation 800-829
- Intracranial Injury 830-839
- Crushing Injury 850-854
- Burn 925-929
- Other Injuries (formerly Electric Shock) 940-949
991-994
Vascular Catheter-Associated Infection 999.31 (CC)
Surgical Site Infection, Mediastinitis, 519.2 (MCC)
Following And one of the following
Coronary Artery Bypass Graft (CABG) procedure codes:
36.10–36.19

28


HAC CC/MCC
Catheter-Associated Urinary Tract Infection 996.64 (CC)
(UTI) Also excludes the following
from acting as a CC/MCC:
112.2 (CC)
590.10 (CC)
590.11 (MCC)
590.2 (MCC)
590.3 (CC)
590.80 (CC)
590.81 (CC)
595.0 (CC)
597.0 (CC)
599.0 (CC)



HAC CC/MCC
Surgical Site Infection Following Certain 996.67 (CC)
Orthopedic Procedures 998.59 (CC)
And one of the following
procedure codes: 81.01-
81.08, 81.23-81.24, 81.31-
81.38, 81.83, 81.85

Surgical Site Infection Following Bariatric Principal Diagnosis – 278.01
Surgery for Obesity 998.59 (CC)
539.01 (CC) or 539.81 (CC)
And one of the following
procedure codes: 44.38,
44.39, or 44.95


29


HAC CC/MCC
Deep Vein Thrombosis and Pulmonary Embolism 415.11 (MCC)
Following Certain Orthopedic Procedures 415.13 (MCC)
415.19 (MCC)
453.40-453.42 (MCC)
And one of the
following procedure
codes: 00.85-00.87,
81.51-81.52, or 81.54


POA Indicators

Indicator Descriptor

Y Indicates that the condition was present on admission.

W Affirms that the provider has determined based on data and
clinical judgment that it is not possible to document when the
onset of the condition occurred.
N Indicates that the condition was not present on admission.

U Indicates that the documentation is insufficient to determine if the
condition was present at the time of admission.
1 Signifies exemption from POA reporting. CMS established this
code as a workaround to blank reporting on the electronic
4010A1. A list of exempt ICD-9-CM diagnosis codes is available
in the ICD-9-CM Official Guidelines for Coding and Reporting.


30

POA Statistics FY11 vs. FY12
POA Indicator Number FY11 FY12
Description (%) (%)
Y Present on 60,206,593 83.69% 80.94%
Admission
W Can not be 13,145 0.02% 0.02%
determined clinically

N Not present on 5,001,138 6.72% 6.72%
admission
U Documentation not 2,223,318 0.21% 2.99%
adequate to
determine if present
on admission

1 Exempt 6,938,487 9.36% 9.33%

Total 74,382,681


POA Statistics FY12
• RTI Report is available at http://www.rti.org/reports/cms/.
• Applies to discharges October 2009 through September 2010
• 3,572 discharges were impacted by the HAC Policy
• Savings of $21,450,095.
• Average case savings of $6,005
• Most frequent category reported the resulted in a re-assignment to the
MS-DRG was Trauma and Falls which resulted in $9,200,708 from
1,672 cases..
• Total of 317,644 cases were reported with HAC conditions as
secondary diagnosis.
• 19,143 discharges (6%) were reported with POA indicator of N or U.
• 94 discharges had 2 HACs reported on the same admission with 15
resulting in MS-DRG reassignment.


31

Medicare Code Edit Update
• Noncovered procedures
– Add 43.82 (laparoscopic sleeve gastrectomylaparoscopic sleeve
gastrectomy)


Surgical Hierarchy
• In Pre-MDC, new MS-DRGs 016 and 017 will be added above
MS-DRG 010 (Pancreas Transplant).

• In MDC 09, new MS-DRGs 570, 571, and 572 will be added above
MS-DRG 579 (Other Skin, Subcutaneous Tissue, and Breast
Procedures with MCC) and below MS-DRG 578 (Skin Graft
Except for Skin Ulcer or Cellulitis without CC/MCC)


32

CC Exclusion List

• The list is available at
http://www.cms.gov/AcuteInpatientPPS/IPPS2011/list.asp#TopOfPage
• Remove diagnosis codes 707.23 (Pressure ulcer, stage III) and 707.24
(Pressure ulcer, stage IV) from the CC Exclusion List when reported with
a principal diagnosis code of 707.0X (where X equals any value 0 - 7, 9).
• Add diagnosis code 585.6 (End-stage renal disease) to the CC Exclusion
List when reported with a principal diagnosis code of 403.90
(Hypertensive chronic kidney disease, unspecified, with chronic kidney
disease stage I through stage IV, or unspecified).
• Add diagnosis code 403.91 (Hypertensive chronic kidney disease,
unspecified, with chronic kidney disease stage V or end-stage renal
disease) to the CC Exclusion List when reported with a principal
diagnosis code of 585.6 (End-stage renal disease).


MS-DRG 15
• Delete MS-DRG 15 (Autologous Bone Marrow Transplant)
• Create MS–DRG 016 (Autologous Bone Marrow Transplant with
CC/MCC); and MS–DRG 017 (Autologous Bone Marrow Transplant
without CC/MCC).


33

MS-DRG 023 and 024
• Assign rechargeable dual array systems for deepbrain stimulation
cases identified by reporting both procedure codes 02.93 and 86.98.


MS-DRGs 237-238
• Removing procedure codes 38.45 and 39.73 from MS–DRGs 237 and
238 and adding these two codes to the following six MS–DRGs: 216;
217; 218; 219; 220; and 221.
• Revise the title of MS–DRG 237 to read ‘‘Major Cardiovascular
Procedureswith MCC.’’
• The title of MS–DRG 238 (Major Cardiovascular Procedures without
MCC) will remain the same.


34

New MS-DRGs 570 - 572
• Based on procedure code 86.22
– MS–DRG 570 (Skin Debridement with MCC)
– MS–DRG 571 (Skin debridement with CC)
– MS–DRG 572 (Skin Debridement without CC/MCC)
• Exclude 86.22 from the following MS-DRGs
– Revised MS–DRG 573 (Skin Graft for Skin Ulcer or Cellulitis with MCC)
– Revised MS–DRG 574 (Skin Graft for Skin Ulcer or Cellulitis with CC)
– Revised MS–DRG 575 (Skin Graft for Skin Ulcer or Cellulitis without
CC/MCC)
– Revised MS–DRG 576 (Skin Graft Except for Skin Ulcer or Cellulitis with
MCC)
– Revised MS–DRG 577 (Skin Graft except for Skin Ulcer or Cellulitis with
CC)
– Revised MS–DRG 578 (Skin Graft Except for Skin Ulcer or Cellulitis without
CC/MCC)


MS-DRGs 640 - 642
Revision of titles for:
• MS–DRG 640 (Miscellaneous Disorders of Nutrition, Metabolism, and
Fluids and Electrolytes with MCC)
• MS–DRG 641 (Miscellaneous Disorders of Nutrition, Metabolism, and
Fluids and Electrolytes without MCC)
• MS–DRG 642 (Inborn and Other Disorders of Metabolism).


35

MS-DRGs 619 - 621
• Add new procedure code 43.82 (Laparoscopic vertical (sleeve)
gastrectomy) and 43.89 (Other total gastrectomy) to MS-DRG 619 –
620 ((O.R. Procedures for Obesity with MCC, with CC, and without
CC/MCC, respectively)
• Add 43.82 to MCE Edit for Non-Covered Procedures


MDC 15 - (Newborns and Other Neonates With Conditions
Originating in the Perinatal Period)
• A change was made to the MS-DRG methodology in FY2011 with
regards to a new discharge status.
• This discharge status was not added to MS–DRG 789 (Neonate, Died
or Transferred to Another Acute Care Facility
• Adoption of Discharge Status 66 (Discharged/Transferred to Critical
Assess Hospital (CAH)) for FY12.


36

MS DRGs 981, 982, 983

– No changes are made for FY 2012


MS DRGs 984, 985, 986

– Prostatic procedures are performed and are unrelated
to the principal diagnosis


37

MS DRGs 987, 988, 989



Updating ICD-9-CM and ICD-10-CM/PCS
• Last major update to occur October 1, 2011 to ICD-9-CM as well as
ICD-10-CM and ICD-10-PCS
• Any urgent code updates between September 2011 and March 2013
would be discussed at the Coordination and Maintenance Committee
meetings
– Determine new technology
– Determine new disease (public health)
• Next major update would be to ICD-10-CM and ICD-10-PCS on
October 1, 2014
• Coordination and Maintenance Committee will continue to meet twice
per year through the transition from ICD-9-CM to ICD-10-CM/PCS.


38

Hospital Inpatients
• Increase the number of diagnoses and procedures to 25 diagnoses and
25 procedures for hospital inpatient claims began January 1, 2011 as
a result of ICD-10 implementation activities.
• Final version of ICD-10 MS-DRGs to be implemented October 1, 2013
will be subject to National Rulemaking.
• Finalizing proposed clarification of the IPPS recalled device policy to
state that the policy applies where ‘‘the hospital received a credit equal
to 50 percent or more of the cost of the replacement device,’’ and we
will issue instructions to hospitals accordingly.


Cost to Charge Ratio FY12

Group CCR
• Routine Days ................................ 0.525
• Intensive Days .............................. 0.453
• Drugs ............................................ 0.199
• Supplies & Equipment .................. 0.329
• Therapy Services .......................... 0.380
• Laboratory ..................................... 0.146
• Operating Room ........................... 0.251
• Cardiology ..................................... 0.155
• Radiology ...................................... 0.140
• Emergency Room ......................... 0.236
• Blood and Blood Products ............ 0.402
• Other Services .............................. 0.402
• Labor & Delivery ........................... 0.454
• Inhalation Therapy ........................ 0.191
• Anesthesia .................................... 0.116


39

New Technologies

• CardioWest™ Temporary Total Artificial Heart System
(CardioWest™ TAH-t)
– Approved for FY 2009, continued payment for FY 2010
– Technology that is used as a bridge to heart transplant
device for heart transplant-eligible patients with end-stage
biventricular failure
– Recent FDA approval
– ICD-9-CM Procedure Code 37.52 with Condition Code 30,
and ICD-9-CM Diagnosis Code V70.7 will trigger add-on
payment
– Maximum add-on payment: $53,000


New Technologies
• Spiration® IBV® Valve System
– Small, temporary, one-way valves placed, via bronchoscopy, into
selected small airways in the lung in order to limit airflow into selected
portions of lung tissue that have prolonged air leaks following
lobectomy; segmentectomy; or lung volume reduction surgery.
– The valves reduce the amount of air that enters the pleural space
– The device has 5 anchors that secure the valve to the airway to help
prevent valve migration
– Valves are intended to be removed no later than 6 weeks after
implantation
– MS-DRGs 163, 164, and 165 (with procedure code 33.71 or 33.73 in
combination with one of the following procedure codes: 32.22, 32.30, 32.39,
32.41, or 32.49)
– MS-DRGs 199, 200, and 201 with diagnosis 512.1 combination with
procedure code 33.71 and 33.73
– Maximum add-on payment of $3,437.50


40

New Technologies

• Auto Laser Interstitial Thermal Therapy (LITT)
– AutoLITT™ is a minimally invasive, MRI-guided laser tipped
catheter designed to destroy malignant brain tumors with interstitial
thermal energy causing immediate coagulation and necrosis of
diseased tissue.
– Treatment of Glioblastoma Multiforme
– Add-on payment is applicable to MS-DRGs 25, 26, 27 with
procedure code 17.61 (Laser interstitial thermal therapy [LITT] of
lesion or tissue of brain under guidance) plus principal diagnosis
beginning with 191.xx.
– Maximum add-on payment of $5,300


New Technologies

• AxiaLIF® 2L+TM System
– This technology is an implantable spinal fixation system, delivered
through a pre-sacral approach, facilitating spinal fusion through
axial stabilization of the anterior lumbar spine at Lumbar vertebrae 4
through Sacral vertebrae 1 (L4–S1).
– Treatment of degeneration of lumbar disc
– Add-on payment is applicable to MS-DRGs 459 and 460 with
procedure code 81.08 ((Lumbar and lumbosacral fusion of the
anterior column, posterior technique)


41

New Technologies

• PerfectCLEAN With Micrillon®
– The manufacturer asserts that PerfectCLEAN is intended to be used
to trap and eliminate pathogens such as Methicillin-resistant
Staphylococcus aureus (MRSA), Clostridium difficile (C diff.) and
the H1N1 flu virus from surfaces within the hospital (as well as other
health care facilities and locations). The applicant asserts that it can
trap and remove more than 99.99 percent of bacteria on hard
surfaces.
– Elimination of pathogens
– Applicable to 622 different MS-DRGs
– Does not meet the criteria


Quality
• RHQDAPU - Reporting Hospital Quality Data for Annual Payment
Update
– Hospital inpatient quality
– High impact for Medicare beneficiary
– Impacted by the Affordable Care Act
– 38 measures for FY12
• PQRI - Physician Quality Reporting Initiative – physician quality
• HOPQDRP - Hospital Outpatient Quality Data Reporting Program –
hospital outpatient quality
• Update factor (if submitting quality data) is 2.35.
• Program measures to be collected by Electronic Health Record in
FY2015.


42

Quality Indicators for FY 2012
Acute Myocardial Infarction (AMI)
AMI-1 Aspirin at arrival (Data collection suspended 1/1/2012 d/c)
AMI-2 Aspirin prescribed at discharge
AMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin
II Receptor Blocker (ARB) for left ventricular systolic dysfunction
Data collection suspended 1/1/2012 d/c)
AMI-4 Adult smoking cessation advice/counseling (Retired 1/1/2012)
AMI-5 Beta blocker prescribed at discharge (Data collection suspended
1/1/2012 d/c)
AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of
hospital arrival
AMI-8a Timing of Receipt of Primary Percutaneous Coronary
Intervention (PCI)
AMI-10 Statin prescribed at discharge


Heart Failure (HF)
HF-1 Discharge instructions

HF-2 Left ventricular function assessment

HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or
Angiotensin II Receptor Blocker (ARB) for left
ventricular systolic dysfunction

HF-4 Adult smoking cessation advice/counseling (Retired
1/1/2012)


43

Pneumonia (PN)
PN-2 Pneumococcal vaccination status

PN-3b Blood culture performed before first antibiotic received in
hospital

PN-4 Adult smoking cessation advice/counseling (Retired
1/1/2012)
PN-5c Timing of receipt of initial antibiotic following hospital arrival
(Retired 1/1/2012)
PN-6 Appropriate initial antibiotic selection

PN-7 Influenza vaccination status


Surgical Care Improvement Project (SCIP)
SCIP-1 Prophylactic antibiotic received within 1 hour prior to surgical
incision
SCIP-3 Prophylactic antibiotics discontinued within 24 hours after
surgery end time
SCIP-VTE-1 Venous thromboembolism (VTE) prophylaxis ordered for
surgery patients
SCIP-VTE-2 VTE prophylaxis within 24 hours pre/post surgery
SCIP-Infection-2 Prophylactic antibiotic selection for surgical patients
SCIP-Infection-4 Cardiac Surgery Patients with Controlled 6AM Postoperative
Serum Glucose
SCIP-Infection-6 Surgery Patients with Appropriate Hair Removal (Data
collection suspended 1/1/2012)
SCIP-Infection-9 Postoperative Urinary Catheter Removal on Post
Operative Day 1 or 2


44


Surgical Care Improvement Project (SCIP)
SCIP-Infection-10 Perioperative Temperature Management
SCIP- Surgery Patients on a Beta Blocker Prior to Arrival Who
Cardiovascular-2 Received a Beta Blocker During the Perioperative Period



Mortality Measures (Medicare Patients)
MORT-30-AMI Acute Myocardial Infarction 30-day mortality –
Medicare patients
MORT-30-HF Heart Failure 30-day mortality Medicare patients
MORT-30-PN Pneumonia 30-day mortality –Medicare patients
Patients' Experience of Care
HCAHPS Survey
Readmission Measure
READ-30-HF Heart Failure 30-Day Risk Standardized Readmission
Measure (Medicare patients)
READ-30-AMI Acute Myocardial Infarction 30-Day Risk
Standardized Readmission Measure (Medicare patients)
READ-30-PN Pneumonia 30-Day Risk Standardized Readmission
Measure (Medicare patients)


45


AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators
(IQIs) and Composite Measures

PSI 06 Iatrogenic pneumothorax, adult

PSI 14 Postoperative wound dehiscence

PSI 15 Accidental puncture or laceration

IQI 11 Abdominal aortic aneurysm (AAA) mortality rate (with or
without volume)
IQI 19 Hip fracture mortality rate



AHRQ Patient Safety Indicators (PSIs) Inpatient Quality Indicators (IQIs)
and Composite Measures

Mortality for selected surgical procedures (composite) Retired
Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)
Nursing Sensitive
Death among surgical inpatients with serious, treatable complications

Cardiac Surgery
Participation in a Systematic Database for Cardiac Surgery
Stroke
Participation in a Systematic Clinical Database Registry for Stroke Care


46

Quality Measures
• Measures for FY13
– Retain 55 measures present for FY12
– Add Statins Prescribed at Discharge for AMI patients
– Add HAC
• Central Line Associated Blood Stream Infection (CLABSI) (NQF #0139)
(begin collection January 1, 2011)
• Measures for FY14
– 59 measures projected
– Retain FY13 measures
• Retire PN-2 and PN-7
– Surgical Site Infection (SSI) (NQF #0299) (begin collection January 1, 2012)
– Add two chart based measures
• ED Throughput – Admit Decision Time to ED Departure Time for
Admitted Patients (NQF #0497)
• ED Throughput - Median time from emergency department arrival to ED
departure for admitted patients (NQF #0495) measures.
– Add two global immunizations
• Pneumoccocal Immunization;
• Influenza Immunization.

Post-Acute Care Transfer Policy
• Discharge status
– Patients transferred to a nonparticipating acute care facility should
use discharge status code 02.
– Patients transferred to critical access hospital should use discharge
status code 66.
– An acute care hospital “transfer case” includes a transfer to an acute
care hospital that would otherwise be eligible to be paid under the
IPPS, but does not have an agreement to participate in the Medicare
program, and a new paragraph (b)(4) to state that an acute care
hospital “transfer” also includes a transfer to a CAH.


47

Take Aways from Today
1.

2.

3.


Thank You

Contact information
Laurie M. Johnson, MS,RHIA, CPC-H; Director, ICD-10 Content Development Team
724-295-9682
laurine.johnson@optum.com

48

ICD-9-CM and MS-DRG Update FY 2012

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